CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 353 1032.75 37897.25 36.70
Subtotal (Total Children Is Unduplicated) 353 1032.75 37897.25 36.70
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.00 150.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.00 48.50 48.50
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.50 112.50 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.00 55.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 66.50 4908.00 73.80
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.00 300.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 27.00 1972.00 73.04
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 75.00 4162.50 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 19.50 1462.50 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 23 24.00 1164.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SCREEN-T1023-INTERDISCIPLINARY SCREENING 2 2.00 100.00 50.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 17 17.00 824.50 48.50
Subtotal (Total Children Is Unduplicated) 108 247.50 15599.50 63.03
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.00 519.95 519.95
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 390.00 19500.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 10.00 500.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 56 359.75 24419.83 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.50 81.48 54.32
PHY-97110-PT SESSION BY LICENSED PT 60 319.25 21670.69 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 1.50 81.48 54.32
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 2 5.00 250.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 524.25 35565.75 67.84
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.50 138.60 13.20
Subtotal (Total Children Is Unduplicated) 211 1622.75 102727.78 63.30
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Total 2903.00 156224.53 53.81
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Number of Children (Unduplicated) With at Least One Service 374
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 2181 1501.75 66621.29 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 18 19.50 1010.75 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
608 1381.75 88592.49 0.00
Other 0 0.00 0.00 0.00
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Total 2807 2903.00 156224.53 0.00